2. Definition
• Cervical cancer is a preventable HPV-related
malignancy of the uterine cervical mucosa.
• Cervical mucosa: mean tumor arise from epithelium, i.e: type of
tumor is carcinoma (SCC or adenocarcinoma but SCC is the much
more common type).
• The tumor precisely arise from what’s called TZ.
• HPV – related: b/c of HPV is the most important aetiological factor.
• b/c the natural course of the disease is well known, so it deserve to
have screening test, so the disease is preventable condition.
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3. Epidemiology
• Cervical cancer is the fourth most common
malignancy in women worldwide.
• More common in developing countries b/c of
early sexual activity due to early marriage, low
socioeconomic state & poor nutrition.
• Incidence mainly in women aged between 20 &
49 years with peak incidence in women aged 40-
49 years & the declines gradually thereafter.
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4. Epidemiology (Cont.)
• Incidence higher in black people & mortality is
twice higher than white people.
• Incidence less in muslems & jewishs.
• In developed countries, the incidence start to
decline in the last decades b/c of screening
program.
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5. Aetiology
• The cancer occur following CIN which is widely
regarded as a necessary precursor lesion for
carcinoma of cervix.
• CIN is a histological diagnosis and needs
persistent cervical infection with HPV to develop.
• There are about 15 high risk oncogenic subtypes
of HPV, the most common being 16, 18, 31, and
33 & much more common are 16 & 18.
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6. Risk factors
• Strong:-
• HPV infection (most common factor ever)
• Age group: women aged between 20 & 49 years with peak
incidence in women aged 40-49 & the declines gradually
thereafter.
• HIV infection.
• Early onset of sexual activity (younger than 18).
• Multiple sexual partners.
• Cigarette smoking (as promoter/ precipitating factor).
• Immunosuppression.
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7. Risk factors (Cont.)
• Weak:-
• All other STDs.
• Oral contraceptive use (adenocarcinoma).
• High parity.
• uncircumcised male partner.
• micronutrient malnutrition.
• low serum folate.
• low vitamin C and E levels.
• alcohol abuse.
• low socioeconomic status.
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8. Pathophysiology
• The main site of the cancer is TZ.
• TZ: zone at which transformation from squamous
epithelium to columnar one occur at SCJ.
• This continuous metaplasia suggest high mitotic activity
in this area making TZ is the most susceptible site for the
cancer in the cervix.
• This continuous metaplasia kept by acidic PH of vagina,
so as the age of female progress, then metaplasia tend to
creep upward gradually.
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9. Pathophysiology (Cont.)
• Therefore, in young female TZ lies in
ectocervix while in older female
(postmenopause) lies in endocervix.
• In presence of presistent HPV infection in
addition to co-factor as smoking, metaplasia
will change to dysplasia & then driving CIN.
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13. Prevention
• Safe sexual health and effective barrier
contraception.
• Vaccines against HPV-16/18:-
• Vaccination can be done in female aged between 9 to 45 yrs but
recommended age for vaccination is 11 to 12 yrs for all adolescents.
• Regular screening by cervical smear.
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14. Screening
• The NHS Cervical Screening Programme (NHSCSP)
presented since the 1980s.
• Regular cervical screening reduces the risk of death from
cervical carcinoma by 75% (but does not eliminate it).
• cervical cancer Screening is cytological study based on
the natural course of cervical cancer as it detect
possibility of CIN (dysplasia) & depend on cervical smear
(aka; pap smear).
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15. Types of abnormalities seen in smear:-
• Dyskaryosis
• Increased nuclear/cytoplasmic ratio
• Koilocytosis
• Poikylocytosis
• Mitosis
• Inflammation
All these
changes
suggest
presence of
dysplasia
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16. Cervical smear – normal cytology. Cervical smear – severe dyskaryosis.
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17. Results of cervical smear
• Normal
• Abnormal:-
• Inflammation: HPV infected cells + inflammatory cells.
• Dysplasia
o LSIL: HPV infected cells + mild dysplasia
suggesting possibility of CIN-1 on biopsy.
o HSIL: HPV infected cells + moderate dysplasia
suggesting possibility of CIN-2 or CIN-3 on biopsy.
o Cancer: HPV infected cells + severe grades of
dysplasia suggesting invasion on biopsy.
• CIN-1: 1/3
thickness
• CIN-2: 2/3
thickness
• CIN-3: full
thickness
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19. • The USPSTF and the ASCCP guideline now recommend
screening in women from age 21 to 65 years as following:-
o For general population (low risk group): every 3 years.
o For high risk group (HPV infection, early sexual activity, smoker……etc): annually.
o After subtotal hysterectomy, after Tx of benign lesion or CIN: annually.
• In 2012, USPSTF guideline introduce HPV test which indicated as a
part of screening program with pap smear provided that screening
performed each 5 years instead of 3 years or can be indicated in
women with borderline nuclear changes in smear or unsatisfactory
smear results in highly suspicious women clinically.
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20. Spread
• Direct/ local spread (infiltration) :-
o Upwards or down: to body of uterus or vagina.
o Lateral (dangerous): to parametria (including LN) & may affect ureter.
o Ant. or post: to bladder or rectum (ulcer, hge, fistula, edema).
• Distant spread/ metastasis by lymphatic: once para-
arotic LN involved, then this signify poor prognosis &
case is incurable.
• Distant spread/ metastasis by blood (rare & late): BLBL.
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21. Diagnosis
History & examination:-
• Key diagnostic factors:
o presence of risk factors (common).
o abnormal vaginal bleeding (common).
o postcoital bleeding/ contact bleeding (common).
o pelvic pain, dyspareunia (uncommon).
o cervical mass (uncommon).
o cervical bleeding (uncommon).
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22. Diagnosis (Cont.)
• Other diagnostic factors:
o mucoid or purulent vaginal discharge (common).
o bladder, renal, or bowel obstruction (uncommon).
o bone pain (uncommon).
o Other manifestations of local or distant spread
(uncommon).
o Other manifestations of complications (uncommon).
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23. Diagnosis (Cont.)
Investigations:-
• 1st test to order:
ResultsTest
mass or bleeding.vaginal or speculum examination
• Raised edge, irregular contour.
• Abnormal blood vessels (mosaic or punctate).
• Aceto-white areas with acetic acid.
• Yellow-areas with Schiller iodine.
colposcopy
Confirms diagnosis histologically and identifies
subtype.
biopsy
Indicated when pap smear positive but unsatisfactory.HPV testing23
27. Diagnosis (Cont.)
• Differential diagnosis:-
o HPV infection
o Pelvic infection
o Nabothian cyst
o Glandular hyperplasia
o Mesonephric remnants
o Endometriosis
o Cervical polyp
o Cervical fibroid
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28. FIGO system for staging of cervical cancer
• Stage 0: CIN, preinvasive lesion/ no invasion of
BM.
• Stage 1: confined to cervix:
o Stage 1a: microscopic disease/ invasive carcinoma
but not diagnosed unless by biopsy.
o Stage 1b: macroscopic disease/ visible invasive
carcinoma.
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29. FIGO system for staging of cervical
cancer (Cont.)
• Stage 2: extend/infiltrate beyond cervix but
not to pelvic side wall (parametria) or extend
to upper 2/3 of vagina:
o Stage 2a: infiltrate upper 2/3 of vagina.
o Stage 2b: infiltrate parametria.
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30. FIGO system for staging of cervical
cancer (Cont.)
• Stage 3: extend/ infiltrate pelvic side wall or
lower 1 /3 of vagina or associated with non-
functioning kidney or hydronephrosis:
o Stage 3a: infiltrate lower 1 /3 of vagina.
o Stage 3b: infiltrate pelvic side wall or associated
with non-functioning kidney or hydronephrosis.
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32. FIGO system for staging of cervical
cancer (Cont.)
• Stage 4: extend out of true pelvis or infiltrate
bladder or rectum:
o Stage 4a: locally advanced/ extend to adjacent
organ as bladder or bowel.
o Stage 4b: distant metastasis/ extent out of true
pelvis.
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33. UICC staging by TMN system
Less commonly used. T staging corresponds to FIGO
staging.
• TX, NX, MX: primary tumor, nodes, or metastases
not assessed.
• N0, M0: Nodes or metastases not involved.
• N1, M1: Nodes or metastases involved.
• Tis: Carcinoma in situ (correspond to higher
grades of CIN).
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34. Treatment
Patients with cervical cancer classified according stage of disease
at time of presentation for therapeutic purposes into:-
• Non-pregnant patients:-
o Microinvasive disease: stage Ia1.
o Early stage disease: stage Ia2 to IIa.
o Locally advanced disease: stage IIb to IVa.
o Metastatic disease: stage IVb.
• Pregnant patients: same stages & all of them are treated by
same lines of treatment.
In non-
pregnant
patient, each
stage has its
own line of
treatment.
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37. Complications
• Bleeding.
• Bladder instability after radical hysterectomy
• Radiation complications: vaginal stenosis, atrophy,
fibrosis, bladder instability, lymphoedema & bowel or
bladder fistulae.
• Leg oedema after lymphadenectomy.
• Excision & ablation techniques complications: preterm
birth.
• Long term sexual dysfunction.37
38. Prognosis
• Most recurrence happens within 2 years.
• The 5-year survival depends on the stage of the
tumor:
o Stage IA1 - 100%.
o Stage IB2-IIB - 50% to 70%.
o Stage III - 30% to 50%.
o Stage IV - 5% to 15%.
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39. Abbreviations:
• USPSTF: United States Preventive Services Task Force
• ASCCP: American Society for Colposcopy and Cervical Pathology
• FIGO: International Federation of Gynecology and Obstetrics
• UICC: International Union Against Cancer
Sources:
• Oxford Handbook of Obstetrics and Gynaecology 3rd Ed. (2013)
• BMJ: Cervical Cancer: Nov 10, 2017
• Gynaecology by Ten Teachers, 19th Ed. (2011)
• Ain-Shams University Gynaecology curriculum (2013)
• Kasr-Alainy University Gynaecology curriculum (2014)
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